FERRIS STATE UNIVERSITY

DEPARTMENT OF NURSING
OBSTETRIC HISTORY & PHYSICAL EXAM FORM
Student: Melissa Bisel Date: July 17, 2013
Please review GUIDELINES FOR NURSING HISTORIES before beginning.
BIOGRAPHICAL DATA
A. Pt. init. J. D. Age 26 DOB 8/2/86 Reigi!n Cris!ian Ra"e "i!e
B. Mari!al s!a!us #$e$% one& 'ingle Ma##ied 'e(ara!e) Di*or$e) "i)o+e)
C. ,eares! rela!i*e/$u%%!#t %e#$!n #rela!ionsi( only& -usban)
BRIEF SOCIAL HISTORY
A. "ere e.(loye) ,o! e.(loye) /$$u(a!ion ,/A
B. -iges! e)u$a!ion: 2 years $ollege
CURRENT PREGNANCY
A. 01(e$!e) )a!e of )eli*ery: De$e.ber 1 ,2013 G#a&ida 1 2ara 0 A' 0
B. 3y(e of $il)bir! (re(ara!ion: ,one Da!e las! seen by Dr. May 3, 2013
C. Allergies/sensi!i*i!ies: 2eni$illin
D. '(e$ial (roble.s !is (regnan$y an) !rea!.en!: ges!a!ional )iabe!es
0. 4abora!ory assess.en! #if %no+n&:
B!!d t(%e A R) 5 Fat)e#*$ '!!d t(%e / R) 5
Ane.ia6 ,o
7. ,ursing assess.en!:
2re8(regnan! "! 190 lbs. 2resen! "! 203 lbs -! : f!. 6 in.
G+ Min!# di$"!,-!#t$ .")e"/ a t)at a%%(01
; Moo) s+ings ,o$!uria ; 2ain #+ere&
Dys(areunia Ba$%a$e <aginal )is$arge
; 7a!igue ; 4eg $ra.(s ; ,u.bness or $2eing of -eet, -inge#$, an/e$
<ari$osi!ies ; Cons!i(a!ion ; =!$ing of $/in or *ul*a
=nso.nia ; 7re>uen! urina!ion /!er:
-ear! Burn ; An1ie!y
-a*e you a) or been e1(ose) !o a .a?or infe$!ion6 @es, A(ril 8, 2013
#"a!& Abs$ess on !ail bone +i$ +as re.o*e)
=<. 2A'3 -0A43- A,D M0,'3ABA4 -='3/A@
"ri!e in !is s(a$e (er!inen! infor.a!ion rela!e) !o resi)ual or $roni$ illness.
CCCCCCC,oneCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
4as! ;8rays May 7, 2013 3y(e Cer*i$al #Measure $er*i$al leasions&
"a! .e)i$a!ions an) *i!a.ins are you !a%ing an) +y6 2rena!al *i!a.ins #(regnan$y&, Dofran
#nausea&, 3ylenol #!oo! (ains&
V+ PAST CONTRACEPTIVE HISTORY
; /ral =BD Eels F 7oa.s Ay!.
,or(lan! Con)o.s ; D02/ 2ro*era ; (a!$
A+ P#e&i!u$ P#egnan"( Hi$t!#(1NA
D/B 'e1 Bir! +eig! 2re./73/'!illbir! 4i*ing
B. 2re*ious $il)ren +i! (roble.s af!er bir!6 01(lain ,A
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
C. 2roble.s +i! (re*ious (regnan$ies #e1$essi*e *o.i!ing, .ul!i(le bir!s, e1$essi*e +!.
gain, $losely s(a$e) (regnan$ies, e!$.& 01(lain ,A
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
D. 2roble.s +i! (re*ious labors an)/or )eli*eries #e1!en)e) labor (erio)s, e1$essi*e
blee)ing, abnor.al fe!al (osi!ion, e!$.& 01(lain ,A
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
0. 2os!(ar!u. (roble.s #sub8in*olu!ion, infe$!ion, e1$ess blee)ing, bla))er, e!$.&
01(lain ,A
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
<=. DIET ASSESSMENT
,o. of .eals (er )ay 3 ,o. of sna$%s (er )ay 1 !o 2 7lui) in!a%e (er )ay 60 .4
2i$a CC,oCCCCCC 2e$uliari!ies #so$ial8$ul!ural, religious, e$ono.i$, e!$.& ,o
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
T(%i"a Dai( F!!d Inta/e in 345)# %e#i!d .$a,%e0
B#ea/-a$t Lun") Dinne# Sna"/$
7oo) A.oun! 7oo) A.oun! 7oo) A.oun! 7oo) A.oun!
Bagel G
$eeseburger
G Ci$%en 3 oH
s!ra+berries
2
Crea. $eese
2 3bls.
7ren$ fries
20 'ala) G C. 'ni$%ers G
NUTRITION LIMITATIONS
"a! )o you $onsi)er !o be your eal!y +eig!6 1I0 lbs.
Do you ea! a! leas! 3 .eals a )ay6 @es
Are you on a s(e$ial )ie!6 ,o
Do you !a%e foli$ a$i)6 ,o
Do you a*e $urren! or (as! (roble. +i! an ea!ing )isor)er6 ,o
Do you a*e any )en!al (roble.s6 @es, +is)o. !ee!
"en +as your las! $e$% u(6 2011
Do you a*e any *ision (roble.s6 @es, s!ig.a!is. in bo! eyes
Can you ear +i!ou! (roble.s6 @es
Do you a*e any s(ee$ (roble.s6 ,o
Do you a*e any learning (roble.s6 ,o
Do you a*e any (ysi$al li.i!a!ions6 Can run be$ause bro%e lef! an%le re$en!ly
FEARS6ANXIETIES ABOUT PREGNANCY AND PARENTING
2ersonal -eal!: ges!a!ional )iabe!es, s!re!$ .ar%s, +eig! gain
2ersonal 'afe!y: ,one
7e!al Con)i!ion: fe!al gro+!, Do+nJs syn)ro.e #7a.ily is!ory&
0arly 2regnan$y 4oss: ,o
2regnan$y Co.(li$a!ions: ,o
-os(i!al: ,o
'urgery: )oesnJ! +an! C8se$!ion
Anes!esia: e(i)ural
2erina!al 4oss: )uring )eli*ery
4abor/Deli*ery: +orrie) abou! baby ge!!ing s!u$% an) a*ing e(isio!o.y
=nfan! =llness: ,o
=nfan! A!!a$.en!: ,o
2aren!ing '%ills: ,o
A. 2er$e(!ion an) %no+le)ge of (regnan$y an) )eli*ery #in $lien!Js o+n +or)s&
K= feel li%e = %no+ a lo! abou! (regnan$y an) )eli*ery be$ause of .y .o. an) sis!erLM
B. A!!i!u)e !o+ar) (regnan$y Aeally e1$i!e) abou! a*ing a baby bu! )oes no! li%e $urren!
$anges !o bo)y
C. Nues!ions as%e) by .o!er8!o8be: "a! +oul) $ause .e !o be i!$y6
7OR86SCHOOL ACTIVITIES EXPOSURE
-a*e you e1(erien$e) !e loss of a $o8+or%er an)/or frien) a! +or% or s$ool6 @es,
frien)
-a*e you been !rea!ene) re$en!ly a! +or% or s$ool6 ,o
-a*e you been in*ol*e) in an argu.en! or fig! a! +or% or s$ool6 ,o
-a*e you re$en!ly $ange) ?obs6 @es, >ui! ?ob
-a*e you re$en!ly $ange) s$ool6 ,o
Nui! s$ool6 ,o
Do you use ea*y e>ui(.en!6 ,o
Do you +or% long ours6 ,o
Do you )o ea*y ouse+or%6 @es
Do you of!en s!an) for 30 .inu!es or .ore a! a !i.e6 @es
Do you of!en lif! .ore !an 20 (oun)s6 @es
Do you a*e (roble.s $li.bing s!airs6 ,o
Do you (lay s(or!s6 ,o
Do you ri)e in a $ar .ore !an 1 our a )ay6 'o.e!i.es
Do you a*e a )isabili!y !a! li.i!s a$!i*i!y6 ,o
Are you e1(ose) !o:
2ain! !inners or o*en $leaners6 ,o
'!rong $leaners6 ,o
Ca! li!!er6 ,o
Mer$ury or lea)6 ,o
Cera.i$s, s!aine) glass, or ?e+elry .a%ing (ro)u$!s6 ,o
-a*e you ea!en ra+ or un$oo%e) .ea!6 ,o
Do you +ear your sea! bel!6 @es
-o+ .any se1ual (ar!ners a*e you a) in !e (as! year6 1
Are you no+ using/!a%ing or a*e you e*er !a%en/use) ar) )rugs6 ,o
"i$ one#s&6 CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
A.oun! CCCCCCCCCCCCCCCCCCCCCCCCC 7re>uen$y CCCCCCCCCCCCCCCCCCCCCCCCCC
-o+ .any $igare!!es )o you s.o%e )aily6 0 Any .ariuana6 ,o
Do o!ers s.o%e aroun) you6 @es
-o+ .u$ al$ooli$ be*erage )o you )rin% (er )ay/+ee%6 ,one
HOUSEHOLD SOCIAL SUPPORT RESOURCES
-o+ .any $il)ren )o you $are for in your o.e6 /
Ages: CCCCCCCCCCCCCCCC
Do you $are for a fa.ily .e.ber +i! a )isabili!y6 ,o
Do you a*e a serious illness6 ,o
Ae$en! or (lanne) .o*e6 @es
Do you feel slee(y or !ire) a lo!6 @es
Do you feel safe +ere you li*e6 @es
Do you or anyone in your ouse e*er go !o be) ungry6 @es
Do you a*e any (roble.s !a! %ee( you fro. eal! $are a((oin!.en!s6 ,o
Do you a*e fa.ily +o +ill el( you6 ,o
Do you a*e frien)s you $an $oun! on +en you nee) el(6 @es
Are you no! ge!!ing along +i! or arguing +i! your:
2ar!ner: ,o
2aren!: DoesnJ! !al% !o (aren!s
7rien)s: 3al%s !o goo) frien)s
Cil): ,A
/!er CCCCCCCCCCCCCCCC
Do you a*e a $ar or a$$ess !o !rans(or!a!ion6 @es
Do you a*e a$$ess !o a !ele(one6 @es
Do you re$ei*e:
7oo) '!a.(s: @es
3A,7/"elfare: ,o
-el( +i! Cil) Care: ,A
-el( +i! ousing: ,o
"=C: @es
INFORMATION ON BABY*S FATHER
Do you %no+ for $er!ain +o. !e fa!er of !e baby is6 @es
=f yes, +a! is !e age of !e babyJs fa!er6 30
=s !e babyJs fa!er ere +i! you !o)ay6 @es
-o+ long a*e you %no+n !e babyJs fa!er6 39 (ea#$
=s !e babyJs fa!er a((y abou! your (regnan$y6 @es
Do you $urren!ly li*e +i! !e babyJs fa!er6 @es
Are you .arrie) !o !e babyJs fa!er6 @es
=s !e babyJs fa!er $urren!ly .arrie) !o so.eone else6 ,o
Does !e babyJs fa!er a*e $il)ren no! in !e o.e6 @es
=f yes, o+ .any $il)ren )oes e a*e6 2
"a! is is/er age6 8 F 6
LIFE STRESSORS MENTAL HEALTH VIOLENCE6ABUSE
"as your (regnan$y (lanne)6 ,o
Do you +an! !o (aren! !is $il)6 @es
Do you a*e enoug .oney !o (ay for foo), ousing, F bills6 @es
-a*e you re$en!ly e1(erien$e) an e1!re.ely s!ressful e*en! #ouse fire, !orna)o, )ea!&6
,o
Do you feel o*er+el.e), sa), o(eless, or los! (leasure in !e !ings usually en?oye)6
'o.e!i.es
Are you a*ing any (roble.s slee(ing6 ,o
-a*e you re$en!ly !oug! abou! sui$i)e6 ,o
-a*e you e*er a!!e.(!e) sui$i)e6 "en6 ,o
-a*e you e*er been )iagnose) +i! a .en!al eal! $on)i!ion6 ,o
-a*e you been os(i!aliHe) for a .en!al eal! $on)i!ion6 ,o
Di) you a!!en) or $urren!ly a!!en) .en!al eal! $ounseling6 ,o
Are you e*er afrai) of your (ar!ner6 ,o
=n !e las! year, as anyone a! o.e i!, %i$%e), (un$e), or o!er+ise ur! you6 ,o
=n !e las! year, as anyone a! o.e of!en (u! you )o+n, u.ilia!e) you or !rie) !o
$on!rol +a! you $an )o6 ,o
=n !e las! year, as anyone a! o.e !rea!ene) !o ur! you6 ,o
-a*e you in !e (as! or re$en!ly been a *i$!i. of:
Aa(e/'e1ual Assaul!6 ,o
2as! Ae$en!
Men!al Abuse6 ,o
2as! Ae$en!
Cri.e <i$!i.6 ,o
2as! Ae$en!
-a*e you e*er been in*es!iga!e) for ur!ing or negle$!ing a $il)6 ,o
BABY*S FATHER OR CURRENT PARTNER IN THE HOME
Does !e babyJs fa!er or your $urren! (ar!ner use:
3oba$$o6 ,o
Al$ool6 'o.e!i.es
Mari?uana6 @es
Co$aine6 ,o
=< Drugs6 ,o
Me!6 ,o
=s e bi8se1ual6 ,o
Does e a*e .ul!i(le (ar!ners6 ,o
=s !e babyJs fa!er or your $urren! (ar!ner e.(loye)6 ,o
<==. 2-@'=CA4 A''0''M0,3
Eeneral A((earan$e #D/ ,/3 (u! Kgoo)M or ",4&:
J.D. is $urren!ly in er fif! .on! of (regnan$y, +i$ is !e se$on) !ri.es!er. By
loo%ing a! er you $an !ell !a! se is (regnan! bu! er s!o.a$ is no! big. -o+e*er, +en
= !ou$ er s!o.a$ i! is *ery ar). -er an)s an) fee! a*e .il) s+elling an) er air
as gro+n a lo! sin$e !e las! !i.e = seen er. 'e is s!ill in er regular $lo!es fro.
before (regnan$y an) +ill soon a*e !o buy so.e .a!erni!y $lo!es sin$e !ese ones are
ge!!ing !ig!. -er fa$e is fluse) )ue !o in$rease) or.ones. J.D. loo%s grea! for being 19
+ee%s (regnan!.
Edu"ati!na Need$6Inte#&enti!n$
/n !e basis of your assess.en!, lis! a! leas! T7O nursing )iagnoses for your (a!ien!, in!er*en!ions #.in 3/nursing )iagnosis&, assess.en!s for
ea$ nursing )iagnosis, an) !e ra!ionale for your a$!ions. 2lease a*e su((or!ing e*i)en$e fro. !e li!era!ure for your (lan. Be sure your
assess.en! an) in!er*en!ions $orres(on) !o your ,ursing Diagnosis.
Nu#$ing Diagn!$i$ Ne"e$$a#( A$$e$$,ent$6Inte#&enti!n$ Rati!nae
An1ie!y rela!e) !o:
2ysi$al )is$o.for!s of
(regnan$y
A.bi*alen! an) labile
e.o!ions
7e!al +ell8being
Dis!urbe) bo)y i.age rela!e)
!o ana!o.i$ an) (ysiologi$
$anges of (regnan$y
Defi$ien! %no+le)ge rela!e) !o
firs! (regnan$y as e*i)en$e)
by (a!ien! >ues!ions regar)ing
(ossible $o.(li$a!ions of
8 ,urse +ill )e.ons!ra!e 2 non8(ar.a$ologi$al !e$ni>ues !o
el( +i! an1ie!y
8 2erfor. non8(ar.a$ologi$al !e$ni>ues +en an1ie!y begins
8 3e nurse +ill el( !e (a!ien! !in% of 3 +ays se $an el(
er $urren! si!ua!ion an) af!er 1 +ee% as% !e (a!ien! !o
*erbaliHe !e. ba$%
8 01er$ise a! leas! !ree !i.es a +ee% for 30 .inu!es !o el(
+i! an1ie!y
8'o+ a((ro(ria!e +eig! gain (a!!erns
8Ae(or! a$$e(!an$e of $anges in bo)y i.age
8 3e (a!ien! +ill )e.ons!ra!e an ou!fi! !o !e nurse !a!
.a%es er feel $o.for!able
8 Dis$uss +i! !e (a!ien! eal!y .eals i)eas an) !e
i.(or!an$e of e1er$ise !o re.ain eal!y )uring
(regnan$y
-2a!ien! +ill $orre$!ly lis! signs of (o!en!ial $o.(li$a!ions !a!
$an o$$ur )uring !e se$on) an) !ir) !ri.es!ers
- 2ro*i)e infor.a!ion $on$erning !e (o!en!ial $o.(li$a!ions or
+arning signs !a! $an o$$ur )uring !e se$on) an) !ir)
!ri.es!ers, in$lu)ing (ossible $auses of signs.
- 3e A, +ill e1(lain !e i.(or!an$e of $alling !e eal! $are
A$$or)ing !o 2ou)e*igne #2006&, u( !o 60O of (regnan! +o.en
are ina$!i*e. 3e s!u)y so+s !a! if a (regnan! +o.an e1er$ises
a! leas! !+i$e a +ee% er .oo) +ill in$rease an) se +ill be$o.e
less an1ious. A$$or)ing !o !is s!u)y !ere is a )ire$! lin% be!+een
.oo) an) ina$!i*i!y in (regnan! +o.en.
=n a s!u)y (erfor.e) by Jonson #2013&, e*i)en$e sugges!s !a!
!e $o.(le1i!y of in!era$!ions +i! a)*i$e sour$es, bo)ily
$anges, feelings of $on!rol, as +ell as (er$ei*e) ris%s .ay
e1(lain !e rela!i*e ineffe$!i*eness of +eig! .anage.en!
in!er*en!ions )uring (regnan$y. 7o$using on eal!y )ie! an)
(ysi$al a$!i*i!y le*els .ay be .ore useful an) less )egra)ing
!an fo$using on +eig!.
2rena!al $are is *ery i.(or!an! in all s!ages of
(regnan$y. By a!!en)ing your regularly s$e)ule)
(rena!al a((oin!.en! you $an grea!ly re)u$e !e ris%
of (regnan$y $o.(li$a!ions. A$$or)ing !o Mus!ar)
an) Aoos #199I&, !ere is a $orrela!ion be!+een la$% of
se$on) an) !ir) !ri.es!ers (ro*i)er i..e)ia!ely !o ensure i)en!ifi$a!ion an) !rea!.en! of
(roble.s in a !i.ely .anner.
- 2ro*i)e a +ri!!en lis! of $o.(li$a!ions !o a*e a referen$e lis!
for e.ergen$ies
- 2a!ien! +ill a!!en) all s$e)ule) )o$!orJs a((oin!.en!s

(rena!al $are an) (regnan$y $o.(li$a!ions.
Aeferen$es
Jonson, M. #2013&. "eig! .anage.en! )uring (regnan$y: A sys!e.a!i$ re*ie+ of >uali!a!i*e e*i)en$e.. Midwifery, 12, 6138.
Mus!ar), C. A., F Aoos, ,. 2. #199I&. 3e rela!ionsi( of (rena!al $are an) (regnan$y $o.(li$a!ions. American Journal of Public Health,
84#9&, 1I:081I:7.
2ou)e*igne, M. '., F /Connor, 2. J. #2006&. A re*ie+ of (ysi$al a$!i*i!y (a!!erns in (regnan! +o.en an) !eir rela!ionsi( !o (sy$ologi$al
eal!. Sports Medicine, !#1&, 19838.
EAAD=,E ABBA=C 7/A /B /A ,0"B/A, A''0''M0,3
Be!2 E:%e"tati!n$ Need$ I,%#!&e,ent Meet$ E:%e"tati!n$ E:"e%ti!na
A+ A$$e$$,ent #1: (oin!s&
Assess.en! as P12 blan%
s(a$es, as (oor analysis
#20 (oin!s&
Assess.en! as 9812 blan%s
#2: (oin!s&
Assess.en! as :88 blan%
s(a$es, analysis nee) !o be .ore
in )e(!
#30 (oin!s&
Assess.en! as no blan% s(a$es
an) e1$e(!ional analysis
B+ Nu#$ing diagn!$i$ #0 (oin!s&
Does no! $o.(le!e !e $are (lan
#1: (oin!s&
Cooses ina((ro(ria!e nursing
)iagnoses base) on !e
assess.en!
#17 (oin!s&
Cooses 182 a((ro(ria!e nursing
)iagnoses base) on !e
assess.en!
#20 (oin!s&
Cooses 3 a((ro(ria!e nursing
)iagnoses base) on !e
assess.en!
C+ Inte#&enti!n$ #0 (oin!s&
Does no! a*e any in!er*en!ions
#1: (oin!s&
-as $osen ina((ro(ria!e nursing
in!er*en!ions
#17 (oin!s&
Cooses 283 a((ro(ria!e nursing
in!er*en!ions for ea$ )iagnosis
#20 (oin!s&
Cooses I or .ore a((ro(ria!e
nursing in!er*en!ions for ea$
nursing )iagnosis
D+ Rati!nae -!# inte#&enti!n$ #0 (oin!s&
Does no! a*e any ra!ionales for
in!er*en!ions
#1: (oin!s&
'!a!e) ina((ro(ria!e ra!ionales
for nursing in!er*en!ions
#17 (oin!s&
'!a!e) a((ro(ria!e ra!ionales for
nursing in!er*en!ions for ea$
)iagnosis
#20 (oin!s&
=n8)e(! )is$ussion of !e
nursing in!er*en!ions for ea$
)iagnosis +i! e*i)en$e8base)
su((or! ou!si)e of !e1!boo%s
E+ G#a,,a#; $%eing; &
"a#it( !- idea$
#2 (oin!s&
P10 errors in gra..ar or
s(ellingQ i)eas are no! $learly
(resen!e)
#: (oin!s&
R10 errors in gra..ar or
s(ellingQ i)eas are al.os! al+ays
$learly (resen!e)
#7 (oin!s&
R: errors in gra..ar or s(ellingQ
i)eas are $learly (resen!e)
#10 (oin!s&
A2A for.a! is e1$ellen!Q no
errors in gra..ar or s(ellingQ
i)eas are $learly (resen!e)